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General NPI Number Information
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NPI Number | 1548428170
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Entity Type | Organization
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Legal Business Name | LIGHTHOUSE PSYCHOLOGICAL SERVICES INC
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Dates
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Enumeration Date | 05/30/2008
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Last Update Date | 08/12/2021
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Provider Practice Location Address
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Address Line | 1551 PAYNE AVE
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City | SAINT PAUL
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State | MN
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Zip | 55130-3218
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Country | US
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Telephone | 763-780-3077
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Fax |
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Provider Business Mailing Address
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Address Line | 1314 81ST AVE NE
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City | SPRING LAKE PARK
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State | MN
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Zip | 55432-2116
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CFO
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Name | MRS. MOLLY PAVEK OLSON
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Credential | MA
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Telephone | 763-780-3307
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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